15 January 2010

Betsy was 85 years old, living independently, and in near-perfect health. Her daughter brought her in when she abruptly became short of breath. I saw her with her three adult daughters at the bedside. She was a bit gray, had labored breathing, with an irregular pulse at 135, and hypoxic. She certainly looked critically ill, but was cheerful and as talkative as the circumstances permitted. Her oldest daughter was a CCU Nurse Supervisor. I went over the differential with her – MI, Pulmonary Embolism, Atrial Fibrillation, Congestive Heart Failure, Pneumonia – and sent off a slew of labs. Her EKG was fast but unexciting, and her chest x-ray was essentially normal. Labs came back unusually quickly, and were unremarkable except for a mildly elevated Troponin, a heart enzyme indicative of a heart attack in progress. Just then the nurse told me that her EKG had changed and that Betsy had developed severe chest pain.

Sure enough, a repeat EKG showed an obvious, massive heart attack in progress, with marked ST elevation. This was actually a good thing, since a) now I knew what was going on, and b) it was treatable. I discussed the options with the family, and they indicated that they wanted the full treatment, so after quick call to the on-call cardiologist, who was dubious but professional, the cardiac cath lab was called in. I wrote the standard orders – morphine, beta-blocker, heparin, etc – and moved on to the next patient in the queue. The Emergency Department was just swamped, with waiting times over three hours. No sooner had I finished examining a young lady with pneumonia than I was paged overhead stat to Betsy’s room.

When I got there, she was dead. Unmistakably so. Her skin was waxen and yellow, and she was not breathing; the monitor reflected a heart rate of 30, but I knew that there would be no pulse if I checked her wrist. It is amazing how obvious it can be when the vital force has departed a body. Taking this in a fraction of a second, I reflexively said “Well, this isn’t good.” Her daughters looked at me with tears in their eyes and the eldest said “We know. We’re okay with it.” I turned off the cardiac monitor and removed the oxygen mask from her face. A few words of condolence and I left them alone. I called the cardiologist back, a bit ruefully, and cancelled the case. We called the chaplain, and I moved on back into the realm of the living.

It’s a bit curious. I’ve always said: “As an ER doctor, most of my patients come in alive and will leave alive no matter what I do; a few come in dead and leave dead. Rarely someone comes in dead and leaves alive, which is a victory, and occasionally someone comes in alive and leaves dead, which I take as a personal offense.” But in this case I wasn’t offended. It was the most natural, wholesome (if there can be such a thing) death I have ever been privileged to witness. It was quick and relatively painless, the whole family was there, and everybody was emotionally in tune with it. I hope I go as well. I’m still kind of shocked at how quick it was. As an ER doc, I see a lot of death, and it’s usually more of a process than an event, and there’s usually a longish time between when it begins and when it is irreversible. Not so with Betsy. There one minute, gone the next.

"This was actually a good thing, since a) now I knew what was going on, and b) it was treatable."

As a fellow ER doc, I know what you are trying to say. But I fear that to a non-professional, you saying that a STEMI is "a good thing" means you are putting ease of medical decision-making ahead of the reality of a life-ending event.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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